nursing process
Which step involves collecting both subjective and objective data?
Assessment
Rationale: Assessment is the first step, collecting measurable (objective) and reported (subjective) data.
Which organ is the primary site of drug metabolism?
Liver
Rationale: The liver metabolizes most drugs before excretion.
Which adventitious breath sound indicates fluid in alveoli?
Crackles
Rationale: Crackles are caused by air passing through fluid-filled alveoli.
Which device delivers 1–6 L/min, FiO₂ 24–44%?
Nasal Cannula
Rationale: Low-flow device, humidify if >4 L/min.
A nurse creates a goal: “Client will report pain ≤3/10 within 24 hours.” Which step is this?
Planning
Rationale: Planning includes measurable, time-bound goals.
Which of the “Six Rights” is violated if insulin is given 2 hours late?
Right time
Rationale: Medications must be given at the prescribed time.
A patient with asthma has high-pitched musical sounds on expiration. What are these?
Wheezes
Rationale: Wheezes indicate airway narrowing.
Which mask must run at ≥5 L/min to prevent CO₂ rebreathing?
Simple Face Mask
Rationale: At lower flows, CO₂ can accumulate.
Which step requires documenting the effectiveness of an intervention?
Evaluation
Rationale: Evaluation determines if outcomes were met and guides changes to the care plan.
At what angle should an intradermal injection be given?
5–15 degrees
Rationale: TB skin tests are given at a shallow angle into the dermis.
Which respiratory rate is expected in an adult?
12–20 breaths per minute
Rationale: This is the normal adult range.
Which device delivers the highest O₂ concentration without intubation?
Non-Rebreather Mask
Rationale: Provides 60–100% FiO₂ if bag remains 2/3 inflated.
Which task may be delegated to an unlicensed assistive personnel (UAP)?
Measuring vital signs
Rationale: UAPs may perform routine tasks, but not assessments or teaching.
What is the nurse’s first action if a medication error occurs?
Assess the patient
Rationale: Patient safety comes first before reporting the error.
An O₂ saturation of 88% indicates what condition?
Hypoxemia requiring intervention
Rationale: <90% SpO₂ is critical.
Which device is best for COPD patients needing precise O₂ delivery?
Venturi Mask
Rationale: Delivers controlled FiO₂ (24–60%).
Which step is applied when a nurse identifies patterns and trends in the client’s data?
Analysis/Diagnosis
Rationale: The analysis step involves interpreting assessment findings to identify health problems.
A provider orders Codeine 20 mg PO q6h PRN. The solution is 10 mg/5 mL. How many mL should the nurse give?
10 mL
Rationale: (20 ÷ 10) × 5 = 10 mL.
Which sound indicates upper airway obstruction and is a medical emergency?
Stridor
Rationale: Stridor = high-pitched inspiratory sound, often life-threatening.
Which device can deliver up to 60 L/min and provides some PEEP?
High-Flow Nasal Cannula
Rationale: Heated, humidified O₂, improves oxygenation in acute failure.